Health in the Heartland: Charting a Pathway for Rural Internal Medicine Residencies

In the opening paragraphs of this perspective, authors Taylor Zabel and Matthew Tobey cite from Cosby et al.1, and note that US rural and urban mortality began to diverge in 1990 and the gap has continued to widen ever since.

An overview published by Janice Probst et al. in 2019 in Health Affairs suggests that these disparities are “due in part to declining health care provider availability and accessibility in rural communities” […] “exacerbated by ‘structural urbanism’—elements of the current public health and health care systems that disadvantage rural communities”.2 Probst et al. reach this conclusion after analyzing data from the Centers for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research (WONDER) database for 2017, as well as data from the Department of Agriculture Economic Research Service updated in 2019. In addition, Probst et al. draw attention to the fact that “the poverty gap between rural and urban populations has been steadily declining” […] and “the proportion of rural adults with a college degree, while remaining lower than the rate in urban areas, has increased from 15.5 percent in 2000 to 19.0 percent in 2015”. Nevertheless, the gap in age-adjusted death rates in rural vs urban populations for all demographic groups continues to widen.

The data suggests that while increasing the availability of health care providers alone may not be sufficient to eliminate the mortality gap between urban and rural populations, it is a necessary step towards achieving the goal of health equity for all. The medical community in particular and the nation in general must work together to achieve this health equity if we want to have a successful, healthy, thriving workforce—and the continued presence of fresh food on our tables from our nation’s farms.

For most urban dwellers, the words “equity” and “minority” evoke images of “urban decay” and stereotypical “at risk” populations, and not images of our rural brethren, yet data from the Economic Research Service of the US Department of Agriculture show that only 14%—a minority—of the US population lives in rural areas. If the medical community at large aims to improve the health of the population, then we must advocate for the health of people who live in rural areas as passionately as we do for those who live in urban areas.

Another complication in the rural health landscape is the rapid increase in the elderly population that began in 2012, as projected by the United States Census Bureau,3 and the fact that rural populations, on average, skew older and sicker than their urban counterparts. Adults ages 65 to 74 years of age “use much greater levels of physician services relative to the non-elderly”; therefore, “the rapid growth of the elderly population portends a significant increase in demand for physician services”.3

The current physician-to-population ratio in rural areas is 12 per 100,000 for internal medicine and 49.2 per 100,000 for family medicine.4 These numbers fall far short of the estimated requirements for primary care physicians as calculated by the Physician Requirements Model (PRM) developed by the Health Resources and Services Administration (HRSA), of 175 per 100,000 in persons ages 65 to 74 years old.3 Furthermore, if the supply of rural physicians continues to decline as currently predicted,5 the gaps between rural populations and their urban counterparts will continue to deepen.

Zabel and Tobey share some insights about the facilitating factors and barriers that they encountered as their academic medical center (AMC)—Massachusetts General Hospital—implemented a graduate medical education program in partnership with a rural health facility in South Dakota.

The HRSA Rural Residency Planning and Development Technical Advisory Center created a Roadmap6 for those willing to undertake this daunting task, but even before think-tanks at prestigious AMCs can begin to evaluate community assets and assemble local leadership to determine the new program’s mission, funding must be secured.

This requires an understanding of how graduate medical education is financed and the rules that govern the distribution of the approximately $16 billion yearly CMS budget, a disproportionally small percentage of which is allocated to rural training programs. In general, hospitals that house training programs can access this funding in two ways7: directly, by financing the resident’s and faculty’s salaries, or indirectly—which represents about 70% of the $16 billion budget—by increasing the reimbursement rates for inpatients at training facilities. The formulas used to calculate exactly how much money each training facility gets are rooted in antiquated assumptions not only about the costs of residency training, but also the location where said training takes place. And since Medicare formulas are tied to Medicare patient volumes, a children’s hospital in a sparsely populated rural area, for example, will find itself at a significant disadvantage.

In an attempt to remediate some of the inherent inequities that are baked into these outdated rules and reverse the potentially catastrophic trend of physician shortages in rural areas compounded by the increase in rural hospital closures over the last decade, CMS published a rule in December 20218 that implements changes to direct and indirect Medicare GME payments for academic medical centers that offer Rural Training Programs (RTPs) in the form of a Rural “track” within a non-rural residency. This new rule also sets guidelines for the distribution of 1000 New Medicare-Funded Residency Positions to both urban and rural underserved areas.9 The rule also adds a new definition of RTPs as “ACGME-accredited programs in which residents/fellows gain both urban and rural experience with more than half of the education and training for a resident/fellow taking place in a rural area”.

While these changes present a welcome opportunity to think creatively and build new partnerships with people who live outside our usual area of influence, there are additional barriers to rural residency training expansion that this CMS rule fails to address: unlike FM residency training, IM requires experiences in intensive care units and inpatient subspecialty rotations, and with continued rural hospital closures over the last decade, the choice to pursue a rural residency track would also mean to voluntarily incur the additional costs of housing and travel to the partnering urban AMC for these experiences. Having to relinquish the assurances that come when working in a well-established program with a proven track record and future career opportunities is a risk that the trainee would also have to accept.

The authors propose various approaches that would decidedly make rural residency training more appealing, such as expanding IM fellowships in rural heath equity, networking between rural IM residencies to enhance curricular and program design, collaborate with existing rural FM, OB/GYN, and psychiatry faculty to advance teaching and scholarship among others. RTPs would also help advance institutional missions of diversity, equity, and inclusion.

If an act of Congress and the commitment of a world-renowned prestigious institution with a very high concentration of some of our brightest minds are not able to effect broader change, then we need to rethink what we as a nation consider health care to be. Is it a right? If so, then we must stop funding individuals and start funding communities. As long as moneys are tied to individual characteristics such as age and employment status—in the form of Medicare and employer-based insurance—rather than our collective humanity, then we will continue to allow our neighbors to be second class citizens who are not worthy of the privilege of health. And all of us will have to pay the cost, not only in the form of the most expensive health care system among industrialized nations, but also of the cost savings we forego by choosing to pay for expensive disability and loss of income instead of inexpensive preventative care.

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